Collecting Cancer Data: Webinar Hematopoietic and Lymphoid Series - - PDF document

NAACCR 2016‐2017 Webinar Series 11/3/16 Hematopoietics 1

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NAACCR 2015-2016 Webinar Series

Collecting Cancer Data: Hematopoietic and Lymphoid Neoplasms

NAACCR 2015‐2016 Webinar Series

Presented by: Angela Martin amartin@naaccr.org Jim Hofferkamp jhofferkamp@naaccr.org

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• Please submit all questions concerning webinar content through the

Q&A panel.

• Reminder:
• If you have participants watching this webinar at your site, please collect

their names and emails.

• We will be distributing a Q&A document in about one week. This

document will fully answer questions asked during the webinar and will contain any corrections that we may discover after the webinar.

Q&A

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Fabulous Prizes

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• Hematopoietic Database and Manual
• Questions/Answers from Ask SEER Registrar
• Quiz
• Staging
• Quiz
• Case Scenarios

Agenda

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Overview

Hematopoietic & Lymphoid Neoplasms

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• Use to screen all reports except cytology and tumor markers
• Can use equivalent terms “favored” rather than “favor(s)” but not substitute

synonyms “equal” for “comparable with”. Do not substitute “likely” for “most likely”

• Accept reportable term used even if another part of medical record uses a

term not on the reportable list

• Followback is recommended
• If biopsy or physician’s statement confirms non‐reportable do not report
• Do not report ambiguous cytology

Ambiguous Terminology

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Apparently Most likely Appears Presumed Comparable with Probable Compatible with Suspect(ed) Consistent with Suspicious (for) Favor(s) Typical (of) Malignant appearing

Ambiguous Terminology

Hematopoietic and Lymphoid Neoplasm Coding Manual pg23

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• No priority hierarchy
• Use Code 1 ONLY when tissue, bone marrow, or blood used to

diagnose specific histology

• Originally confirmed by histology (Code 1) and then

immunophenotyping, genetic testing or JAK2 confirms more specific with no evidence of transformation – Code 3

• Hematopoietic and Lymphoid Neoplasm Coding Manual pg 13

Diagnostic Confirmation

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Microscopically Confirmed

• Code 1 – Positive histology
• Bone marrow specimens
• Peripheral blood smear (9590/3‐9992/3)
• Flow cytometry
• Leukemia only (9800/3 – 9948/3) – CBC, WBC
• Microscopically confirmed AND
• Immunophenotyping, genetic testing or JAK2 not done OR

done but negative

• Code 2 – Positive cytology (rarely used)

Diagnostic Confirmation

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Microscopically Confirmed

• Code 3 – Positive histology PLUS
• Positive immunophenotyping AND/OR
• Positive genetic studies
• Code 4 – Positive microscopic confirmation, method not

specified

• Rarely used;

Diagnostic Confirmation

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Not Microscopically Confirmed

• Code 5 – Positive Lab test/marker study; rarely used
• Code 6 – Direct visualization w/o microscopic confirmation
• Code 7 – Radiology and other imaging techniques w/o microscopic

confirmation

• Code 8 – Clinical diagnosis only

Confirmation Unknown

• Code 9 – Unknown whether or not microscopically confirmed,

DCO

Diagnostic Confirmation

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Transformations

• A chronic neoplasm is a neoplasm that can transform TO an

acute/more severe neoplasm

• CLL/SLL (9823/3)
• Diffuse large B‐cell lymphoma (9680/3)
• An acute neoplasm is a neoplasm that may have transformed

FROM a chronic neoplasm

• Plasma Cell myeloma (9732/3)
• Solitary plasmacytoma of bone (9731/3)

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The Database

Hematopoietic & Lymphoid Neoplasms

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Five steps to using the Hematopoietic Database

• Identify the working histology code(s)
• Determine the number of primaries
• Verify or revise the working histology code(s)
• Determine primary site
• Determine the grade

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A patient is diagnosed at your facility in 2016 with acute myeloid

• leukemia. Looking in your registry database you see that the

patient was diagnosed and treated for refractory anemia with ring sideroblasts in 2010.

Example

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• Refractory anemia with ring sideroblasts
• 9982/3
• Acute myeloid leukemia
• 9861/3

Step 1: Identify the working histology code(s)

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• Rule M10: Abstract as multiple primaries when a neoplasm is
• riginally diagnosed as a chronic neoplasm AND there is a

second diagnosis of an acute neoplasm more than 21 days after the chronic diagnosis.

• Note 1: Use the Heme DB multiple Primaries Calculator to

determine the number of primaries when a transformation from a chronic to an acute neoplasm occurs

Step 2: Determine the number of primaries

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• 2010 – 9982/3
• 2016 – 9861/3

Step 3: Verify or revise the working histology code(s)

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• 2010 – Module 9, PH30 C421
• 2016 ‐ Module 9, PH30 C421

Step 4: Determine primary site

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• 2010 – Grade 9
• 2016 – Grade 9

Step 5: Determine the grade

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Questions/Answers from Ask SEER Registrar

Hematopoietic & Lymphoid Neoplasms

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• Please see below ‐ should this be coded to CLL/SLL 9823/3 or

non reportable FINAL INTERPRETATION Monoclonal B‐cell lymphocytosis ("high count" per WHO 2016) showing the immunophenotype of CHRONIC LYMPHOCYTIC LEUKEMIA/SMALL LYMPHOCYTIC LYMPHOMA. The neoplastic cells are expressing monotypic lambda immunoglobulin light chains.

Question 1

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• Yes, you can use this diagnosis to abstract this case as 9823/3

for CLL/SLL.

Question 1

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• Path reports states: Deep cervical lymph node (excision):

Follicular lymphoma in situ. See note. Note: This diagnosis is rendered in consultation with Dr. Ellen McPhail of the Mayo Clinic in Rochester, MN (order# V7554683). Dr. McPhail states the following in her comment: The findings support the diagnosis of follicular lymphoma in situ. Comment: Follicular lymphoma in situ is of uncertain malignant potential and often will not progress to overt follicular

• lymphoma. Clinicopathologic correlation is strongly

recommended."

Question 2

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• Per the Case Reportability Instructions, #3:

Note: Do not report in situ lesions.

Question 2

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• Patient transformed from 9945/3 to 9895/3, Can we say there is

now no evidence of disease for the 9945/3 since it has transformed into 9895/3?

Question 3

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• If there is no documentation that shows evidence that the

disease is still present, then yes, you can say there is no evidence of disease.

Question 3

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• What diagnostic confirmation code should be used for the

following case 2015 lymphoma case: Patient was diagnosed and treated for T lymphoblastic lymphoma of mediastinum based on pericardial fluid cytology. Immunophenotyping on fluid confirmed the subtype. Bone marrow exam was negative, and the patient did not have a tissue biopsy.

Question 4

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• Since there is immunophenotyping that confirmed the

diagnosis, use code 3.

Question 4

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• How would you code "Anaplastic large cell lymphoma, ALK neg".

The Hematopoietic rules database only shows a code for ALK pos.

Question 5

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• Assign histology 9702/3, Peripheral T‐cell lymphoma, NOS . One
• f the alternate names is "Anaplastic large cell lymphoma, ALk

neg."

Question 5

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• Patient diagnosed with chronic myelomonocytic leukemia

March 2015 and then in June 2015 diagnosed with myeloid sarcoma found in skin, is this a new primary? Looking at rule M3, says chronic myeloid leukemia is the exception to this rule. Although morphology 9945/3 is not one

• f the listed morphologies for chronic in rule M3.
• Then using the MP Calculator, says New primary. NOTE: AML

9861/3 and Myeloid sarcoma 9930/3 also states New primary when using the calculator, but AML, NOS 9860/3 and 9930/3 says Same primary?

Question 6

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• Chronic myelomonocytic leukemia is grouped with the

myelodysplastic/myelodysplasia syndromes. It is not covered in Rule M3. M15 would apply, which is to abstract the second primary of myeloid sarcoma, 9930/3.

• In terms of the multiple primary calculator, only use this when

instructed by the multiple primary rules. Using it at any other time could results in the wrong number of primaries.

Question 6

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• DLBCL (9680/3) of the stomach Nov 2015 and due to

abnormality on PET imaging was found to have plasmablastic lymphoma (9735/3) of the tonsil early December 2015.

• The physician documents Stage IV DLBCL of the stomach and
• tonsil. However, after review of the Heme rules and database, it

appears this is actually 2 separate primaries, correct?

Question 7

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• As a reminder, physician's don't use the same rules that we do.

Sometimes the way physician's count primaries will be different than how we collect them. You are to follow the rules as defined in the Heme Manual and Database

• You are correct, this is 2 primaries. Rule M15 applies, which

states to use the multiple primaries calculator. The MPC shows that the plasmablastic lymphoma (9735/3) is a second primary.

Question 7

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Quiz 1

Hematopoietic & Lymphoid Neoplasms

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AJCC & Summary Stage

Staging Lymphoma

Hodgkin and Non-Hodgkin Lymphoma

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Summary Stage

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• Stage I

– Involvement of a single lymph node region

• Stage IE

– Localized involvement of a single extralymphatic organ/site – Multifocal involvement of one extralymphatic organ/site

• Stage IS

– Localized involvement of spleen only

1 Localized

• Stage II

– Involvement of two or more lymph node regions on the SAME side of the diaphragm

• Stage IIE

– Direct extension to adjacent organs or tissues – Localized involvement of a single extralymphatic organ/site WITH involvement of its regional lymph node(s) or WITH involvement of other lymph node(s) on the SAME side of the diaphragm

• Stage IIS

– Involvement of spleen PLUS lymph node(s) BELOW the diaphragm

• Stage IIES

– Involvement of spleen PLUS localized involvement of a single extralymphatic organ/site BELOW the diaphragm WITH/WITHOUT involvement of lymph node(s) BELOW the diaphragm

5 Regional, NOS

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• Stage III

– Involvement of lymph node regions on BOTH sides of the diaphragm

• Stage IIIE

– Involvement of an extralymphatic organ or site PLUS involvement of lymph node(s) on the OPPOSITE side of the diaphragm

• Stage IIIS

– Involvement of the spleen PLUS involvement of lymph node(s) ABOVE the diaphragm

• Stage IIIES

– Involvement of the spleen PLUS involvement of lymph node region(s) ABOVE the diaphragm PLUS involvement of a single extralymphatic

• rgan/site on either side of the diaphragm

– Involvement of the spleen PLUS a single extralymphatic organ/site ABOVE the diaphragm WITH OR WITHOUT involvement of lymph node(s)

7 Distant

• Stage IV

– Disseminated involvement of ONE OR MORE extralymphatic

• rgan(s)/site(s)

– (Multifocal) involvement of MORE THAN ONE extralymphatic

• rgan/site
• Metastases

– Bone marrow

7 Distant (cont.)

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AJCC & Summary Stage

Staging Lymphoma

Hodgkin and Non-Hodgkin Lymphoma

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• Values

– T, N, and M values are not defined in the AJCC Manual for Hodgkin and Non‐Hodgkin lymphoma. – When values are not defined for the T, N,M or Stage Group data items in the AJCC manual for a site/histology combination, NPCR, CoC, and SEER have all agreed that a value

• f 88 should be entered.

T, N, and M Values

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• Hodgkin or Non‐Hodgkin

Lymphoma with an unknown stage

– T, N, and M are defaulted to 88 – Stage group is 99

T, N, and M Values

Data Item Value Clinical T 88 Clinical N 88 Clinical M 88 Clinical Stage 99 Pathologic T 88 Pathologic N 88 Pathologic M 88 Pathologic Stage 99

• Acute myelogenous

leukemia…what is the stage group?

Pop Quiz

Data Item Value Clinical T 88 Clinical N 88 Clinical M 88 Clinical Stage Pathologic T 88 Pathologic N 88 Pathologic M 88 Pathologic Stage 88 88

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• Clinical

– Biopsy

• Excisional biopsy if lymph nodes

– Imaging

• X‐Ray
• CT
• FDG‐PET

– Bone Marrow

• Pathologic

– Staging laparotomy is required – Essentially abandoned as a stage classification

Rules for Classification

• Involvement of a single

lymph node region

• Involvement of a single

extranodal site

• Involvement of a single

extralymphatic site

Stage I

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• Involvement of two or more

lymph node regions on the same side of the diaphragm

Stage II

• Cervical, supraclavicular, occipital,

preauricular

• Infraclavicular
• Axillary
• Pelvic
• Inguinal/femoral
• If both sides are involved, count as two

lymph node regions

Bilateral Lymph Node Regions

Image source: SEER Training Website

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• Axial

– Mediastinal – Hilar – Para‐aortic – Mesenteric

• Each counts as 1 lymph node region
• Extranodal lymphatic sites each count as 1

region – Spleen, thymus, tonsils, Peyer’s patches

Axial Lymph Node Regions

Image source: SEER Training Website

• Internal mammary *
• Epitrochlear **
• Popliteal **
• Occipital *
• Submental *
• Preauricular **

*Count as one lymph node region **Count as two lymph node regions if both sides are involved

Other Lymph Node Regions

Image source: SEER Training Website

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• Clinical enlargement (without other explanation such as

infection)

• Pathologic diagnosis
• Imaging: nodes larger than 1.5 cm

Defining Lymph Node Involvement

• A patient presented with a palpable

right cervical lymph node that did not respond to standard treatment. A biopsy confirmed lymphoma. Additional work‐up showed enlarged left and right cervical lymph nodes. No additional disease was identified.

• What is the stage?

Pop Quiz

Data Item Value Clinical T 88 Clinical N 88 Clinical M 88 Clinical Stage Pathologic T 88 Pathologic N 88 Pathologic M 88 Pathologic Stage 2 99

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• Involvement of one

extralymphatic site with regional lymph node involvement

• Direct extension from a lymph

node to an extralymphatic site

• All involvement is on one side
• f the diaphragm

Stage IIE

• Spleen (C42.2)
• Thymus Gland (C37.9)
• Lingual Tonsil (C02.4)
• Palatine Tonsil (C09.9)
• Waldeyers’s ring (C14.2)
• Peyer’s patches (C17.2)
• Lymphoid nodules of the appendix (C18.1)

Extranodal Lymphatic Sites

These sites are NOT designated by an “E” in the stage group

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• Brain
• Breast
• Large Intestine
• Others

Common Extralymphatic Sites

These sites are designated by an “E” in the stage group

• Stomach
• Small Intestine
• Uterus
• Bone
• Unequivocal palpable splenomegaly
• Equivocal palpable splenomegaly with radiologic confirmation
• Radiologic enlargement AND multiple focal defects (not cystic
• r vascular)

Spleen Involvement (“S” Suffix)

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Code Label Description None There are no prefix or suffix descriptors that would be used for this case 1 E‐ Extranodal, lymphomas only A lymphoma case involving an extranodal site 2 S‐ Spleen, lymphomas only A lymphoma case involving the spleen 3 M‐Multiple primary tumors in a single site This is one primary with multiple tumors in the organ

• f origin at the time of diagnosis

5 E&S‐ Extranodal and spleen, lymphomas only A lymphoma case with involvement of both an extranodal site and the spleen 9 Unknown, not stated in patient record A prefix or suffix would describe this stage, but it is not know which would be correct

Clinical Stage Descriptor

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• A patient is found to have a primary

parotid lymphoma. Staging work‐ up shows the lymphoma is confined to the parotid gland. The entire parotid gland was removed and pathology confirms the disease was confined to the parotid gland. No further treatment was done.

Pop Quiz

Data Item Value Clinical T 88 Clinical N 88 Clinical M 88 Clinical Stage Pathologic T 88 Pathologic N 88 Pathologic M 88 Pathologic Stage 99 Clin Stage Descriptor 1A 2

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• A patient is found to have a large

mediastinal mass. The mass extends into the left lung. No additional abnormalities were

• identified. A biopsy of the mass

confirms lymphoma.

Pop Quiz

Data Item Value Clinical T 88 Clinical N 88 Clinical M 88 Clinical Stage Pathologic T 88 Pathologic N 88 Pathologic M 88 Pathologic Stage 99 Clin Stage Descriptor 2A 2

• Involvement of lymph

nodes on both sides of the diaphragm

Stage III

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• Involvement on both sides of the

diaphragm

– Involvement of one extralymphatic site with regional lymph node involvement – Direct extension from a lymph node to an extralymphatic site – Involvement of the spleen – Involvement by the spleen and an extranodal site

Stage IIIE

• Diffuse or Disseminated

involvement of more than

• ne extralymphatic organ
• Disease in distant sites

Stage IV

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• Site of origin

– Stomach, colon, brain, uterus

• Most likely extralymphatic

– Bone, lung

• Most likely Stage IV

– Liver, bone marrow, cerebrospinal fluid, pleura

• ALWAYS stage IV

Determining Stage IV Disease Summary

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• Note 1: Each stage should be classified as either A or B according to the absence
• r presence of defined constitutional symptoms, such as:

– 1. Fevers: Unexplained fever with temperature above 38 degrees C; – 2. Night sweats: Drenching sweats that require change of bedclothes; – 3. Weight loss: Unexplained weight loss of more than 10% of the usual body weight in the 6 months prior to diagnosis.

• Note 2: Pruritus alone does not qualify for B classification, nor does alcohol

intolerance, fatigue, or a short, febrile illness associated with suspected infections.

• Note 3: Use code 000 if the History and Physical, progress notes, or consultations

make no mention of B symptoms.

• Every stage group should have an A or B
• If B symptoms are coded in SSF 2, then stage group must have a B

SSF 2

• Distant mets can be coded in these data

items for lymphoma!

– Do not use code 8 (not applicable) for lymphoma primaries – Code bone marrow involvement for any site except for primary site bone marrow as code 1 in Mets at Dx‐Other – Code a positive peripheral blood smear as code 1 in Mets at Dx‐Other – Carcinomatosis may be coded as 2 in Mets at Dx Other

Mets at DX BBDLLO

Data Items Mets at Dx Bone Mets at Dx Brain Mets at Dx Distant Lymph Node Mets at Dx Liver Mets at Dx Lung Mets at Dx Other

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Questions?

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Quiz 2 and Case Scenarios

Thank You!